Get Professional Certification Form - Clearcaptions

This guide provides a step-by-step approach to completing the Professional Certification Form for ClearCaptions. This form is essential for individuals with hearing loss to access captioning services at no cost.

Follow the steps to complete your Professional Certification Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the personal information for the individual with hearing loss in the designated fields. This includes their name, street address, city, state, ZIP code, phone number, and email address.
3. Next, provide the details of the certifying healthcare professional or their designee. Enter the professional’s name, title, business or practice name, street address, city, state, ZIP code, phone number, and email address.
4. Select the appropriate designation by checking one of the provided options, which includes audiologist, ENT, general practice physician, physician assistant, nurse practitioner, hearing instrument specialist, geriatrician, pediatrician, or other.
5. Review the certification statements carefully. These statements confirm that the healthcare professional has determined the individual's hearing loss and understands the service funding. Ensure all boxes are acknowledged and completed as required.
6. The certifying healthcare professional should print their name, sign the form, and date it in the respective fields to certify the application.
7. Once all the required fields are filled out and signed, you can save your changes. Then, proceed to download, print, or share the completed form as needed.

Get started on completing your Professional Certification Form online today!